Symptomatic Postoperative Spinal Epidural Hematoma Research Articles

Delayed neurological dysfunction following posterior laminectomy with lateral mass screw fixation: A case report and review of literature

BACKGROUND While most complications of cervical surgery are reversible, some, such as symptomatic postoperative spinal epidural hematoma (SEH), which generally occurs within 24 h, are associated with increased morbidity and mortality. Delayed neurological dysfunction is diagnosed in cases when symptoms present > 3 d postoperatively. Owing to its rarity, the risk factors for delayed neurological dysfunction are unclear. Consequently, this condition can result in irreversible neurological deficits and serious consequences. In this paper, we present a case of postoperative SEH that developed three days after hematoma evacuation. CASE SUMMARY A 68-year-old man with an American Spinal Injury Association (ASIA) grade C injury was admitted to our hospital with neck pain and tetraplegia following a fall. The C3-C7 posterior laminectomy and the lateral mass screw fixation surgery were performed on the tenth day. Postoperatively, the patient showed no changes in muscle strength or ASIA grade. The patient experienced neck pain and subcutaneous swelling on the third day postoperatively, his muscle strength decreased, and his ASIA score was grade A. Magnetic resonance imaging showed hypointense signals on T1 weighted image (T1WI) and T2WI located behind the epidural space, with spinal cord compression. Emergency surgical intervention for the hematoma was performed 12 h after onset. Although hypoproteinemia and pleural effusion did not improve in the perioperative period, the patient recovered to ASIA grade C on day 30 after surgery, and was transferred to a functional rehabilitation exercise unit. CONCLUSION This case shows that amelioration of low blood albumin and pleural effusion is an important aspect of the perioperative management of cervical surgery. Surgery to relieve the pressure on the spinal cord should be performed as soon as possible to decrease neurological disabilities.

Complications of Unilateral Biportal Endoscopic Spinal Surgery for Lumbar Spinal Stenosis: A Meta-Analysis and Systematic Review

In recent years, unilateral biportal endoscopic spinal surgery has been used for the treatment of lumbar spinal stenosis with good results. Some investigators counted the total incidence of complications in unilateral biportal endoscopic surgery for lumbar spinal stenosis, but none have analyzed the incidence of specific complications. The present study further counted the incidence of specific complications and gave the possible causes of the complications. English databases including PubMed were searched to collect relevant literature on unilateral biportal endoscopic spinal surgery for lumbar spinal stenosis. The inquiry period is from January 1, 2015, to July 1, 2022. The literature was screened, information extracted, and risk of bias evaluated by the researchers, followed by Meta analysis using R4.2.1 and RStudio statistical software. In total, we included 14 studies involving 707 patients. The included studies were retrospective case series, The results of the single-arm rate meta-analysis showed that the total complication rate of unilateral biportal endoscopic surgery treatment of lumbar spinal stenosis was 8.1% (95% confidence interval [CI] [0.060; 0.103]); of which, the highest incidence of dural tear was 4.5% (95% CI [0.030; 0.064]), the incidence of symptomatic postoperative spinal epidural hematoma was approximately 1.1% (95% CI [0.001; 0.027]), the incidence of incomplete decompression was 2.0% (95% CI [0.007; 0.038]), the incidence of transient palsy was 2.6% (95% CI [0.005; 0.057]). The incidence of total complications of unilateral biportal endoscopic surgery for lumbar spinal stenosis was 8.1%, dural tear remained a major complication with an incidence of 4.5%, incomplete decompression was 2.0%, transient palsy was 2.6%, and, unexpectedly, symptomatic postoperative spinal epidural hematoma was only 1.1%.

Symptomatic postoperative spinal epidural hematoma preferentially occurs after anterior cervical discectomy and fusion versus anterior cervical corpectomy and fusion: a retrospective study.

Cervical spondylotic myelopathy (CSM) is a common cause of neurological morbidity, which can have an impact on quality of life. Symptomatic postoperative spinal epidural hematoma (SPSEH) is a rare condition, but can cause permanent neurological deficits and disability if not managed properly. However, there are limited studies on the outcomes of SPSEH after anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) were performed for 2-level CSM. Therefore, the aim of the present study was to compare the clinical outcomes and incidence of SPSEH after ACDF compared with SPSEH after anterior cervical corpectomy and ACCF for 2-level CSM to reduce surgical complications of 2 level CSM. A total of 551 patients (261 males and 290 females) who underwent ACDF or ACCF for 2-level CSM from January 2009 to February 2015 were retrospectively reviewed. Preoperative indexes (age, sex, body mass index, bone mineral density, preoperative coagulation, and past medical history), perioperative indexes (length of hospital admission, blood loss, and operation times), preoperative and postoperative neurological statuses, complications, fusion rate, and the SPSEH incidence for ACDF or ACCF were compared simultaneously. With the exception of blood loss (P<0.001), no significant differences were observed between the 2 groups in terms of sex, prothrombin time, activated partial thromboplastin time, platelet count, length of hospital admission, operation time, the final follow-up Japanese Orthopedic Association score, visual analog scale score, fusion rate, and complications. The overall incidence rate for SPSEH after ACDF was 1.9%, while the rate for SPSEH after ACCF was 0.4%. Following hematoma removal, only one patient showed any improvement in neurological function, despite treatment with hyperbaric oxygen and neurotrophic drugs. The findings indicated that surgical management of 2-level CSM using ACDF or ACCF showed similar clinical outcomes, fusion rate, complications, and perioperative parameters, with the exception of blood loss. However, SPSEH preferentially occurs after surgery with ACDF. Therefore, whether ACCF surgery for 2-stage CSM is the superior treatment modality.

Factors Affecting Postoperative Spinal Epidural Hematoma and the Optimal Order of Vertebral Body Decompression in Multivertebral Microendoscopic Laminectomy

PurposeSymptomatic postoperative spinal epidural hematoma (POSEH) is a complication of spine surgery that occurs infrequently but may cause ongoing serious neurological damage. Due to the narrow entry portal, the risk of hematoma is increased after microendoscopic laminectomy (MEL) compared with conventional open surgery, and the risk might be even higher for multivertebral MEL (m-MEL). The purpose of this study was to clarify the factors affecting the development of POSEH after m-MEL and identify the optimal order for the decompression of vertebral bodies.MethodsA total of 313 patients who underwent m-MEL from 2016 to 2020 were retrospectively assessed. The cohort comprised 238 patients who underwent two-level MEL, 67 who underwent three-level MEL, and eight who underwent four-level MEL. Symptomatic POSEH was defined as the presence of an epidural hematoma at the surgical site on MRI with symptoms such as lower extremity pain or muscle weakness. We elucidated the incidence of POSEH at each vertebral level and investigated the relationship between POSEH and possible risk factors such as clinical and operative variables.ResultsThere were 41 patients in the POSEH group and 272 patients in the non-POSEH group. Seven patients in the POSEH group underwent reoperation. The occurrence of POSEH was related to the number of decompressed vertebral bodies. Patients who underwent L2/3 and L3/4 decompression at the end of the procedure also showed a higher incidence of POSEH at the surgical level.ConclusionIn patients undergoing m-MEL, treatment of the upper lumbar vertebrae at the end of decompression surgery might be a risk factor for symptomatic POSEH. The incidence of POSEH was particularly increased at L2/3, suggesting that L2/3 decompression should not be performed at last and that careful hemostasis should be applied.

Effectiveness of Gelatin-Thrombin Matrix Sealants (Floseal®) on Postoperative Spinal Epidural Hematoma during Single-Level Lumbar Decompression Using Biportal Endoscopic Spine Surgery: Clinical and Magnetic Resonance Image Study.

Background Symptomatic postoperative spinal epidural hematoma (PSEH) is a devastating complication that could develop after lumbar decompression surgery. PSEH can also develop after biportal endoscopic spine surgery (BESS), one of the recently introduced minimally invasive spine surgery techniques. Gelatin-thrombin matrix sealant (GTMS) is commonly used to prevent PSEH. This study aimed at analyzing the clinical and radiological effects of GTMS use during BESS. Methods A total of 206 patients with spinal stenosis who underwent decompression by BESS through a posterior interlaminar approach from October 2015 to September 2018 were enrolled in this study. Postoperative magnetic resonance imaging (MRI) was performed in all patients for evaluation of PSEH. Patients in whom GTMS was not used during surgery were assigned to Group A, and those in whom GTMS was used were classified as Group B. In the clinical evaluation, the visual analog scale (VAS) of the leg and back, Oswestry Disability Index (ODI), and modified MacNab criteria were used. The incidence rate and degree of dural compression of PSEH on postoperative MRI were measured. Results The average age of the patients was 68.1 ± 11.2 (42–89) years. The overall incidence rate of PSEH was 20.9% (43/206). The incidence rates in Groups A and B were 26.4% and 13.6%, respectively, showing a significant difference (p = 0.023). The VAS-leg and ODI improvement was significantly different depending on the intraoperative use of GTMS. However, there was no statistically significant difference between the two groups in terms of the VAS-back improvement. Groups A and B showed “good” and “excellent” rates according to the modified MacNab criteria in 79.4% and 87.6% of patients, respectively, showing statistically significant difference (p = 0.049). In Group A, two patients underwent revision surgery due to PSEH, while none in Group B had such event. Conclusion Intraoperative use of GTMS during BESS may be related to reduction in the occurrence rate of PSEH. Specifically, patients with GTMS appliance showed marked decrease in the occurrence of PSEH and had better clinical outcomes.

Symptomatic Postoperative Spinal Epidural Hematoma after Spinal Decompression Surgery: Prevalence, Risk Factors, and Functional Outcome.

Postoperative spinal epidural hematoma (pSEH) with symptomatic compression of nervous structures after spinal decompression surgery is a rare complication. Delayed evacuation may result in severe neurologic impairment. We present a large single-center analysis of the prevalence, potential risk factors, and functional recovery after pSEH. A retrospective review of our institutional database of spinal decompression surgery over 15 years yielded 6,024 consecutive patients. A total of 42 patients who had undergone surgical revision due to postoperative neurologic deterioration or intractable radiating pain and radiographically confirmed pSEH were allocated to the pSEH group. A matched 3:1 control group was formed (126 patients with the same surgical procedure, same year, same sex, and similar age). Charts, surgical reports, and radiographic data were reviewed for demographics, duration of symptoms, history of medical treatment, medication, comorbidities, radiographic extension, surgical strategy, and pre- and postoperative neurologic performance. Median follow-up was 3 months. Risk factors for pSEH, complete recovery, and recovery of neurologic symptoms were analyzed with univariable and multivariable logistic regression models. The prevalence of pSEH in this population was 0.69% (n = 42) with these locations: 7 of 1,284 (0.54%) cervical, 1 of 774 (0.12%) thoracic, and 34 of 3,966 (0.85%) lumbar. Use of anticoagulants (p = 0.003), pathologic coagulation values in the preoperative blood test (p = 0.034), and cigarette smoking (p = 0.003) were identified as independent risk factors of pSEH. Surgery in more than one level showed a trend toward an increased risk of pSEH. Pain as the only symptom (p = 0.0001) was a significant predictor of complete recovery. Patients symptomatic with paraplegia (p = 0.026) had a significantly higher risk of a poor neurologic outcome without full recovery of neurologic symptoms. The prevalence of pSEH was lower than previously reported incidences. Use of anticoagulants, pathologic coagulation values, and cigarette smoking were identified as independent risk factors of pSEH. Functional outcome was related to the duration between hematoma evacuation and the clinical presentation of symptomatic pSEH.

Symptomatic postoperative spinal epidural hematoma after spine tumor surgery: Incidence, clinical features, and risk factors.

Case-control study. The objective of this study was to provide some useful information concerning the incidence, clinical features, and risk factors for symptomatic postoperative spinal epidural hematoma (SPSEH) in an isolated cohort of patients undergoing spine tumor surgery. Hospital in Shanghai, China. We retrospectively reviewed all patients who underwent surgery for spine tumors between August 2012 and August 2017, and conducted a case-control study involving 16 patients who received evacuation surgery due to SPSEH after spine tumor surgery and 48 controls without SPSEH. Case and control subjects were matched at 1:3 by pathological diagnosis, tumor size (±1 cm), resection mode, surgical approach, and the operation team. Data of SPSEH subjects along with 48 matched controls were further obtained from a detailed review of the medical records. Univariate and multivariate analyses were conducted to identify the risk factors for developing SPSEH. SPSEH evacuation surgery was performed after 16 of 5421 (0.30%) spine tumor surgeries. Angiogenic tumors were the most susceptible tumors developing SPSEH. Very large hematomas, continuous blood loss, and delayed hematomas were characteristic clinical presentations for SPSEH after spine tumor surgery. Multiple logistic regression analysis suggested that patients suffering from at least one medical comorbidity and patients with Frankel grade of A-C had a significantly higher risk of developing SPSEH. The incidence of SPSEH after spine tumor surgery requiring surgical evacuation was 0.30%. Medical comorbidity and Frankel grade were identified as independent risk factors for SPSEH development.

Evaluation of Postoperative Spinal Epidural Hematoma After Biportal Endoscopic Spine Surgery for Single-Level Lumbar Spinal Stenosis: Clinical and Magnetic Resonance Imaging Study

Symptomatic postoperative spinal epidural hematoma is a serious complication that may occur after lumbar spine surgery. We analyzed epidural hematoma using postoperative magnetic resonance imaging (MRI) after biportal endoscopic spinal surgery and its impact on clinical outcome. The subjects of this study were 158 patients who underwent single-level decompression using the biportal endoscopic spinal surgery technique from 2015 to 2017. MRI was performed in all patients before and after surgery, and postoperative MRI was used to identify epidural hematoma. The preoperative and postoperative visual analog scale (VAS) score for leg and back pain, Oswestry Disability Index (ODI), and modified Macnab criteria were recorded for evaluation of clinical outcome. The group with postoperative spinal epidural hematoma (group A) and without hematoma (group B) were comparatively analyzed, both radiologically and clinically. The mean age of the patients was 67.9 ± 11.1 years (range, 49-89). The total number with grade 0 (no hematoma) was 119 levels patients (75.3%) on the T2 axial image of postoperative MRI. The total number of patients with hematoma was 39 (24.7%) according to T2-weighted axial postoperative MRI. Two patients underwent revision surgery because of hematoma-related symptoms. The improvement of clinical outcome measures including VAS leg, VAS back, and ODI was significantly different between group A and B (P < 0.05). The incidence of postoperative spinal epidural hematoma after biportal endoscopic spinal surgery according to postoperative MRI was higher than expected, regardless of the patients' postoperative symptoms. Postoperative hematoma has a decisive influence on postoperative results, and revision surgery might be necessary if canal encroachment is >50% with concomitant symptoms.

Impact of lumbar hypolordosis on the incidence of symptomatic postoperative spinal epidural hematoma after decompression surgery for lumbar spinal canal stenosis.

Potential associations between radiographic parameters and the incidence of symptomatic postoperative spinal epidural hematoma (PSEH) have not been identified. This study aimed to identify risk factors including radiographic parameters for symptomatic PSEH after posterior decompression surgery for lumbar spinal canal stenosis (LSS). We retrospectively reviewed 1007 consecutive patients who underwent lumbar decompression surgery for lumbar spinal canal stenosis (LSS) at our institution. We identified 35 cases of symptomatic PSEH, defined by clinical symptoms and MRI findings, and selected 3 or 4 age- and sex-matched control subjects for each PSEH subject (124 controls). We compared radiographic parameters and previously reported risk factors between PSEH and control subjects. Compared to the control group, PSEH patients had significantly higher preoperative systolic (p = .020) and diastolic (p = .048) blood pressure, and more levels of decompression (p = .001). PSEH and control subjects had significant differences in lumbar lordosis (PSEH 24.8° ± 14.6°, control 34.8° ± 14.5°), pelvic tilt (25.1° ± 11.7° vs. 20.8° ± 8.4°), sacral slope (23.4° ± 9.4° vs. 27.6° ± 8.3°), and pelvic incidence minus lumbar lordosis (23.7° ± 15.0° vs. 13.7° ± 14.6°). Multivariate analysis revealed two significant risk factors for PSEH: decompression of two or more levels and lumbar lordosis < 25°. Multilevel decompression and hypolordosis are significant risk factors for symptomatic PSEH after decompression surgery for LSS. LSS patients with lumbar hypolordosis or multilevel stenosis should be carefully observed for PSEH after decompression surgery. These slides can be retrieved under Electronic Supplementary Material.

The impact of hypertension on the occurrence of postoperative spinal epidural hematoma following single level microscopic posterior lumbar decompression surgery in a single institute.

Postoperative spinal epidural hematoma (PSEH) is one of the most hazardous complications after spine surgery. A recent study has reported that a ≥50mmHg increase in systolic blood pressure after extubation was a significant risk factor for symptomatic PSEH. In this paper, the impact of hypertension on PSEH occurrence was investigated. Among a total of 2468 patients who underwent single level microscopic posterior decompression surgery for lumbar spinal stenosis in a single institute, 15 (0.6%) received evacuation surgery for PSEH. Those 15 patients were investigated statistically compared with a randomly selected control group (n=46) using the Mann-Whitney U test and multiple logistic regression analysis. The univariate analysis showed that there were no significant differences in age, gender, BMI, pre-operative anti-coagulant usage, intraoperative blood loss, operation time, and the rate of patients who received pre-operative hypertension treatment. However, there were significant differences in the rate of patients who showed high blood pressure at admission (66.7 vs 6.5%) and >50mmHg increases in blood pressure after extubation (53.3 vs 17.4%) in the univariate analysis. Moreover, postoperatively, there was a statistical difference in the amount of post-operative drainage. Multiple logistic regression analysis showed that high blood pressures at admission and poor postoperative drainage were the essential risk factors. Our results demonstrate that the pre-operative high blood pressure value was the most essential risk factor for PSEH, although there was no difference in the preoperative hypertension treatment. Consequently, management of pre-operative blood pressure and post-operative drainage will be crucial for preventing PSEH.

Large Increase in Blood Pressure After Extubation and High Body Mass Index Elevate the Risk of Spinal Epidural Hematoma After Spinal Surgery.

Matched case-control study. To identify factors other than a multilevel procedure that increase the risk of symptomatic postoperative spinal epidural hematoma (SEH). Postoperative SEH is a potentially devastating complication of spinal surgery. Previous studies that reported risk factors for postoperative SEH all identified a multilevel procedure as a risk factor, but the other risk factors remain unclear. Patients who developed postoperative SEH requiring surgical evacuation were identified from database. Each patient was matched with 3 controls who underwent spinal decompression at the same number of levels in the same part of the spine by the same surgeon during the preceding or following year. Multiple logistic regression analysis was performed to identify the risk factors for postoperative SEH to obtain adjusted odds ratios with 95% confidence intervals. Clinical outcomes after evacuation were investigated separately divided with or without severe paralysis or time until the second surgery. Postoperative SEH evacuation was performed after 32 of 8250 (0.39%) spinal decompression procedures. The incidence was significantly higher after thoracic procedures (2.41%) than after cervical (0.21%) or lumbar (0.39%) procedures. Multivariate analysis identified a 50 mm Hg or greater increase in systolic blood pressure after extubation (adjusted odds ratio: 3.22, 95% confidence interval: 1.22-8.51) and higher body mass index (adjusted odds ratio 1.15, 95% confidence interval: 1.01-1.31) as risk factors. Among 14 patients with severe paralysis due to postoperative SEH, those who underwent evacuation within 24 hours of the onset had a significantly better improvement in clinical outcome and Frankel grade than did those after 24 hours. A 50 mm Hg or greater increase in systolic blood pressure after extubation and high body mass index were identified as risk factors for SEH. Appropriate blood pressure control especially at the end of surgery is important for the prevention of postoperative SEH, particularly in obese patients. 3.

Spontaneous resolution of tetraparesis because of postoperative cervical epidural hematoma

Background context Symptomatic postoperative spinal epidural hematoma (PSEH) is a rare but potentially devastating postoperative complication, accounting for 0.1% to 0.2% of cases. Purpose To describe a patient with a PSEH that completely resolved, clinically and radiographically, without surgical treatment. Study design Case report and review of the literature. Methods A 47-year-old man with no history of a bleeding disorder underwent anterior cervical interbody fusion for C5–C6 disc herniation. The dura was exposed through removal of the posterior longitudinal ligament, and extensive decompression of posterior osteophytes of C5 and C6 vertebral bodies was performed. The patient developed tetraparesis and respiratory distress rapidly in the postanesthesia care unit and was reintubated for assisted ventilation. The computed tomography (CT) scan revealed a very large ventral epidural hematoma compressing the dural sac from C1 to C6. Results The patient was prepared for hematoma evacuation. However, the neurological symptoms and respiration problems began to resolve spontaneously before the surgery was started. The hematoma was markedly improved on the follow-up CT scan, and the patient was discharged 2 weeks after surgery without neurological deficit. Conclusions This case illustrates that an unpredictable extensive hematoma can occur after uneventful surgery of the cervical spine in low-risk patients. In case of the dural exposure with a creation of hidden and large epidural space, the spine surgeon must pay particular attention to the possibility of a PSEH during the early postoperative period.